Angiodysplasia is a vascular malformation that commonly affects the ascending colon and caecum of elderly patients. It is associated with age and can cause intermittent bleeding that ranges from subtle to brisk. The bleeding is often due to dilated, tortuous submucosal veins or vessels replacing the mucosa. Diagnosis involves colonoscopy, which reveals small reddish lesions, or other techniques like capsule endoscopy, angiography, or scans. Treatment focuses on cauterization or embolization of bleeding vessels during colonoscopy or angiography. For severe uncontrolled bleeding, surgery may be needed to locate and remove the bleeding segment of colon.

2. Angiodysplasia
MUHAMMAD ABU BAKKAR KHAN

3. Causes of profuse per rectal bleeding
 Angiodysplasia
 Diverticulitis
 Ulcerative colitis (UC)
 Ischemic colitis

4. Angiodysplasia (Angioectasia)
 Angiodysplasia is a vascular malformation associated with ageing.
 Its true incidence is probably not known because of the spectrum of
disease severity, with ranges in the literature from 5 to 25% over the age
of 60 years.
 With the advent of more sophisticated investigative tools, this may rise.
Angiodysplasias occur particularly in the ascending colon and caecum
(the antimesenteric border) of elderly patients.
 The malformations consist of “dilated tortuous submucosal veins” and, in
severe cases, the mucosa is replaced by massive dilated deformed
vessels.

5. Clinical features
 In the majority, the symptoms are subtle.
 Patients can present with anemia.
 About 10–15% can have brisk bleeds which present as melaena or
significant per rectum bleeding that is often intermittent.

6. Association
 Heyde’s syndrome: There is association of aortic valve stenosis with
gastrointestinal bleeding from colonic angiodysplasia.
 mild form of von Willebrand’s disease is thought to be involved.

7. Investigations
Colonoscopy
 May show the characteristic lesion in the right colon.
 The lesions are only a few millimeters in size and appear as reddish,
raised areas at endoscopy.
‘Pill’ endoscopy
 new technology
 may detect small bowel lesions.

8. Double-balloon endoscopy
 Useful to detect small bowel lesions
 Retrograde double-balloon endoscopy may allow for careful inspection
of the cecum and ileocecal valve.

9. Angiography
 Selective superior and inferior mesenteric angiography shows the site
and extent of the lesion.
C.T abdomen with contrast
 Appear as focal areas (< 5 mm) of contrast enhancement in the bowel
bowel wall (most prominent in the enteric phase )
 Early filling of an antimesenteric vein.

10. Radioactive test
 Using technetium-99m (99mTc)-labelled red cells may confirm and
localize the source of hemorrhage.
 Scanning can detect bleeding with rates as low as 0.1 mL/min.
 The intermittent bleeding nature of angiodysplasia has limited the utility of
radionuclide studies in this disorder.

11.  Barium enema is usually unhelpful and should be avoided,
not least because it may mask the lesion at subsequent
endoscopy. Provided that the bleeding is not too brisk,

12. Treatment
 The first principle is to stabilize an unstable circulation.
 Following this, the bleeding needs to be localized by
colonoscopy. This allows simple therapeutic procedures
such as cauterization to be carried out.

13.  In severe uncontrolled bleeding, surgery becomes necessary.
 On-table colonoscopy is carried out to confirm the site of
bleeding.
 Angiodysplastic lesions are sometimes demonstrated by
transillumination through the caecum.
 If it is still not clear exactly which segment of the colon is
involved, then a total abdominal colectomy with ileorectal
anastomosis may be necessary.

14. Other options
 Super selective embolization of visceral arterial branches
 Immediate cessation of bleeding
 injection of microcoils, polyvinyl alcohol particles,
gel form, or by selective vasopressin infusion.
Selective infusion of vasopressin is less effective than embolization as a definitive
therapy because of high rebleeding rates associated with its use.

15.  Endoscopic laser photocoagulation
 Angiography : Transcatheter embolization of selected
mesenteric arteries has been quite effective.

16. Endoscopic image of argon plasma coagulation of colonic
angiodysplasia

17. Thank you